"Attending" by Ronald Epstein, Mindfulness, & Prayer

I first heard of mindfulness during my residency training. As an Asian-American, doctor, and as a Christian, I was triply skeptic of something that sounded like culturally appropriated, pseudoscientific, New Age-y spiritualism. My initial impression of mindfulness is an “emptying” of the mind— non-thought, non-rational, beyond-words-transcendentalism— not to mention the possibility of yet another example of Western bastardization of another culture. A white person taking something essentially Eastern and repackaging as their own to be commercialized is something horrific to me.

But I thank God for always pursuing me despite my predispositions because as I learned more and more about mindfulness, it truthfully is quite the opposite. It’s a brain exercise with evidence-based utility . It is a method to focus and avoid distraction; it uses the body and mind to stabilize one’s attention in a way that gently diverts you from mind-wandering and rumination. I find it can be helpful as a tool for my patients suffering from anxiety and depression, for doctors to address burn-out, and as a fresh and gentle way to dip into the waters of religious meditation and prayer.

Mindfulness

What is mindfulness? It is paying attention to the present moment, intentionally and in a non-judgemental way. Another way to say it is: “a way of being in which an individual maintains openness, patience, and acceptance, while focusing attention on an unfolding situation in a nonjudgmental way” (1). Synonyms include (5):

Contemplative practice
Attention training
Awareness training
Compassion training
Practice of presence
Meditation

Science has found neurochemical changes that occur with the practice of mindfulness. Moreover, there are now studies that have found an application in medicine. For example, physicians often cope with stressful encounters through compartmentalization and depersonalization. Mindfulness can help doctors with negative emotions and help them really “be there” with patients (3). In the same way, patients can use it as a tool to improve their health. A 2017 American Journal of Medicine systematic review of studies about mindfulness in the healthcare setting summarized “Nine of 14 studies reported positive changes in levels of stress, anxiety, mindfulness, resiliency, and burnout symptoms” (4).

“Attending:Medicine, Mindfulness, and Humanity” by Ronald Epstein

A gracious doctor recommended I read Attending: Medicine, Mindfulness, and Humanity by Ronald Epstein. Epstein’s 30+ year career studying mindfulness is evident in the splatter of neurology, psychology, Persian poetry, and Zen buddhism interspersed throughout the book. There are poignant stories and real-life vignettes showing how mindfulness can be incorporated into a physician’s life. While at times a little meandering and tangential— especially towards the second-half of the book— I found it genuine in its examples and useful in its referencing of scientific studies to back up the premise.

Here are a few pearls that I summarize (not comprehensively) from the book (5) [click here if you want more exhaustive notes that I wrote]:

Mindfulness focuses your “attention” and undistracts your thoughts
Mindfulness cultivates “curiosity” and making space for new ideas
Mindfulness has a “beginner’s mind;” an attitude of humility; it listens first
Mindfulness helps you “be present” in the moment and this inherently involves your observing, understanding, and regulating your emotions
Mindfulness leads you to a deeper understanding of “yourself”; that it is a evanescent assemblage of ideas, habits, and perspectives

What is the mechanism by which mindfulness affects your life? Epstein goes through this thoroughly, albeit not in a very systematic way. Without specifically delineating it, he states through the act of slowing down and having a presence of mind during a physician’s encounter with a patient (ie procedures, surgeries, interviewing), one can avoid medical errors (ie confirmatory bias, premature closure, search satisficing, sunk costs, etc) and learn to be aware of negative emotions so that they can be addressed in a healthy way.

Here I quote how mindfulness regulates emotions: “For example, [contemplative practitioners] more readily distinguish between I am feeling angry— an emotion that they can control—and I am angry— a person whose anger is part of their identity. They learn to set aside their immediate reactions so that they can respond more mindfully.” Then the latter half of the book, he oscillates between the benefits of mindfulness for the physician and the patient— eventually scoping out its personal effect to burnout, the healthcare system, and human suffering as a whole.

True Anthropology

Regardless of religion, conscious of it or not, everyone has a worldview— a set of assumptions about reality and truth. For myself, my worldview is Christian and leads me to discern life by questioning everything in a spiritual context. A Christian lens sees all of life as an opportunity to grow a personal and loving relationship with Jesus. When I learn about mindfulness, I ask “Can mindfulness help me and others grow a personal and loving relationship with Jesus?”

There is a shadow of this in Epstein’s book— a trace and a tease (and a diversion?) of how mindfulness interfaces with ethics, worldviews, and religion. On one hand he states, “Applying focused attention is a moral choice, not just a skill. We pay attention to that which we consider important, and by virtue of paying attention to something, we make it important” (p34). On the other hand he states “It certainly does not require any particular religious or philosophical belief system, other than believing that by knowing yourself better you can be more effective at realizing what is most important.” (p183).

I agree with an article by Dr. Gregory Bottaro, a psychologist and a Catholic, who states, “without grounding mindfulness practice in a ‘true anthropology’—the true nature of the human person—there will always be something missing” (2). Bottaro says there is something missing because he is thinking holistically. As a Family Physician, this is our agenda— to see health holistically: mind, body, emotions, and spirit. Moreover, we know that health care cannot be compartmentalized apart from other social determinants of health (education, economy, social neighborhood, environment) (6). In Attending, Epstein draws lessons from Zen Buddhism and Islamic philosophy, formulates it into the brain exercise that mindfulness is, and naturally applies it to social justice and a greater morality— even ending the title of the book “and humanity”— yet tries to separate it from an anthropology. He’s connecting a personal exercise into something bigger but severs the natural progression to a formal philosophy. If you practice mindfulness but do not think about your understanding of human nature, I think you will always be missing something.

Meditation & Prayer

Mindfulness can be helpful for any worldview (secular or religious). It makes sense that Jon Kabat-Zinn, Professor of Medicine Emeritus and creator of the Stress Reduction Clinic and the Center for Mindfulness in Medicine, Health Care, and Society (at the University of Massachusetts Medical School), one of the most influential and scientific people to bring mindfulness into the Western world, considered himself a Buddhist at one point. Although in later interviews, he evades this description, Kabat-Zinn sees mindfulness as an element of Buddhist philosophy and as a valuable scientific tool to “relieve suffering” (13).

Bottaro describes mindfulness as a tool for us to be aware that “that God is a loving Father who keeps us constantly in his loving care.” While we experience our reality through “time,” in God’s mind it occurs in “one present moment.” Bottaro sees mindfulness as a way to remind us of a specific reality and peace. This is all based on his true anthropology: “human beings are a union of body and spirit made for eternal union with God.”

Richard Foster, a Christian theologian, writes about several aspects and forms of prayer in his book Prayer: Finding the Heart’s True Home. Part of prayer involves the “examen of consciousness” which “is the means God uses to make us more aware of our surroundings.” Whereas the “examen of conscience” is an “inward turning.” This kind of prayer is “not a journey into ourselves that we are undertaking but a journey through ourselves so that we can emerge from the deepest level of the self into God” (14). Prayer is about a unity with God which cannot be separated from your relationship with others and your relationship with yourself.

I’ve found so much joy and empowerment through my personal study of the bible through what Evangelicals call “quiet times” in the morning. I’ve also found myself at awe in intimacy with God through the Catholic tradition of lectio divina. I fondly remember worship songs, retreats, Wednesday night prayer meetings, bible studies, and Christian holidays as opportunities to draw closer in relationship with God. In retrospect, these moments were most meaningful when I was focused and attentive. So many times I’ve fallen asleep (like Jesus’s disciples), was distracted by anxiety or ruminations, or prayed with unexamined motives (external rewards, 12). But when meditation and prayer were done healthily, I find that elements of mindfulness were also present. In those instances, when I was was “truly there” with God— Jesus’s transformation of identity, self-worth, humility, peace, and truth were not just known, but felt in my heart.

Contemplative Prayer

These writers see mindfulness as a tool for something greater. It is a stepping stone— the first step needed for something transformative. The most precise description of this mechanism I’ve found is the three steps of Contemplative Prayer that Foster describes in his book Prayer (14).

Recollection:
- Foster defines this as “a simple recollecting of ourselves until we are unified or whole.” Sue Monk Kidd calls it the prayer of presence. Quakers call this centering down. Jean-Pierre de Caussade calls it “self-abandonment to divine providence.”
- It begins by sitting comfortably and being aware of God’s presence in the room (for he is truly present). If distractions occur, one is not to suppress them but to give them away and release them onto the feet of Jesus.
- Our hearts become still because of our awareness of the intimate and personable God in front of us. We let go of everything because of the promises of a trustworthy and covenant-keeping father. Inner distractions and frustrations melt away because we recollect our belief that nothing is important except attending to him.
Prayer of Quiet:
- When distractions and obstacles are gone, Foster describes this space being available for “divine graces of love and adoration [to] wash over us like ocean waves.” We experience an “inward attentiveness to divine motions.” Our spirit deep inside is awake and “beholding the Lord,” basking in love and warmth of his presence.
- In this step, we are quiet and still but there is no silence because our minds are fully engaged, alive, and listening. This is a stage of a teachable spirit. We are actively listening with our whole mind, heart, spirit, body, and emotions. In this listening stance God’s voice is near and our spirit is impressed with his love.
Spiritual Ecstasy:
- Foster describes this final step as something entirely different than the previous two steps because it is not an action we undertake but “a work that God does upon us.” This is where the experience becomes difficult to describe verbally.
- A salient example is from the well-known passage from 2 Corinthians in which Paul describes an experience of being caught up in the third heaven. There is joy, peace, and euphoria to the nth degree.
- But this experience is more than an emotional high, as many experience the transformative aspect of this state of being primarily from intimacy and oneness with God. Theodore Brakel describes his experience as “seeing God with the eyes of my soul, I felt one with him.”

Foster exclaims that the last step may be more of a fleeting experience than the staple diet of a contemplative life. We are not to be disheartened if our concerns are over the unwashed dishes or the chemistry exam tomorrow. Personally for me, Foster’s outline of Contemplative Prayer has shown how mindfulness prepares the space in your mind and your spirit for something deeply transformative; and transformation of the self can only happen when in the soil of a true reality. Growing a relationship is mostly incremental and these steps are practical and useful for me to deepen a daily communion with God.

Taste & See

My wife and I stayed at a Catholic monastery on a mountain in South Korea shortly after we got married. Her aunt is a cloistered nun who helped us spend a few days in a silent retreat in prayer and in separate rooms (an odd honeymoon right!?). It was dim-lit, quiet, and even a little cold. But through this, I felt an inexplicable draw towards the library and found works from John C. Wu and Thomas Merton which I devoured whole. To me, they’ve accurately placed the wisdom of Buddhism philosophy and mindfulness practice in the Christian context (10) without compromising the grace and work done by Jesus’s death and resurrection. Here, we see Merton explain Zen Buddhism’s popularization in the Western world:

“The fashion of Zen in certain western circles fits into the rather confused pattern of spiritual revolution and renewal. It represents a certain understandable dissatisfaction with conventional spiritual patterns and with ethical and religious formalism. It is a symptom of western man’s desperate need to recover spontaneity and depth in a world which his technological skill has made rigid, artificial, and spiritually void. But in its association with the need to recover authentic sense experience, western Zen has become identified with a spirit of improvisation and experimentation, with a sort of moral anarchy that forgets how much tough discipline and what severe traditional mores are presupposed by the Zen of China and Japan.” (7)

The West has a curiosity for Zen thinking, albeit a one-dimensional curiosity! Merton in another writing, describes a fascinating Christian mechanism between mind and spirit and God (8):

“St. Paul compares this knowledge of God, in the Spirit, to the subjective knowledge that a man has of himself. Just as no one can know my inner self except my own “spirit,” so no one can know God except God’s Spirit; yet this Holy Spirit is given to us, in such a way that God knows Himself in us, and this experience is utterly real, though it cannot be communicated in terms understandable to those who do not share it. Consequently, St. Paul concludes, ‘we have the mind of Christ.’ (1 Cor. 2:16).”

John C. Wu sums up an exquisite understanding (8):

“Unlike technical knowledge, which can be communicated through the intellect alone, spiritual wisdom must be experienced and realized by your whole being—head and heart, body and spirit. When David sang, ‘Taste and see that the Lord is good,’ he was uttering a Zen experience.”

Bridging mindfulness to meditation to Christian prayer is a large undertaking and beyond the scope of this article, but I hope I’ve shared something reasonable and truthful. Focusing the mind on scripture and engaging the affections through meditation can lead to prayer that is truly in communion with God (9, 12, 14)— something one can only understand through experience!

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Awesome Verses

“Therefore I tell you, do not be anxious about your life, what you will eat or what you will drink, nor about your body, what you will put on. Is not life more than food, and the body more than clothing? Look at the birds of the air: they neither sow nor reap nor gather into barns, and yet your heavenly Father feeds them. Are you not of more value than they? And which of you by being anxious can add a single hour to his span of life?” (Matthew 6:25-27)

“I appeal to you therefore, brothers, by the mercies of God, to present your bodies as a living sacrifice, holy and acceptable to God, which is your spiritual worship. Do not be conformed to this world, but be transformed by the renewal of your mind, that by testing you may discern what is the will of God, what is good and acceptable and perfect.” (Romans 12: 1-2)

“Blessed is the one [whose] delight is in the law of the Lord, and who meditates on his law day and night. That person is like a tree planted by streams of water, which yields its fruit in season and whose leaf does not wither— whatever they do prospers.” (Psalm 1)

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Sources:

Dobkin PL, Laliberte V. Being a mindful clinical teacher: can mindfulness enhance education in a clinical setting? Med Teach. 2014;36(4):347-352.
The Present Moment: A Christian Approach to Mindfulness by Gregory Bottaro
Can Mindfulness Meditation Deliver Us From Burnout? – AAFP article
Brief Mindfulness Practices for Healthcare Providers – A Systematic Literature Review from the American Journal of Medicine
Attending: Medicine, Mindfulness, and Humanity by Ronald Epstein
Social Determinants of Health from healthypeople.gov
The Way of Chuang Tzu by Thomas Merton
The Golden Age of Zen: Zen Masters of the T’Ang Dynasty by John C. H. Wu, Jingxiong Wu
Quiet Times, Mysticism, and the Priceless Payoff of Prayer – by Tim Keller
A Christian Looks at Zen by Thomas Merton; I highly recommend reading this as it give a framework to understand Buddhism, Zen, and Christianity in a way that is highly illuminating in the modern context of mindfulness.
Zen: Its Origin and its Significance by John C. H. Wu
The Freedom of Self Forgetfulness: The Path to True Christian Joy by Timothy Keller; a second book that I highly recommend as it combines mindfulness, prayer, and Christian humility and joy. It encapsulates how “Gospel humility is not thinking more of myself or thinking less of myself, it is thinking of myself less.”
Mindfulness and the cessation of suffering: An exclusive new interview with mindfulness pioneer Jon Kabat-Zinn from Lion’s Roar
Prayer: Finding the Heart’s True Home by Richard J. Foster; another book that places mindfulness techniques in the larger context of prayer and meditation

Other readings:

“Listen for your yes” by World Vision – For an examples of 10-minute mindfulness exercises that focus on bible verses, I found these so compelling
Five Mobile Apps for Mindfulness – AAFP recommendations
Mindfulness at Work – AAFP article
Reduce Stress and Thrive Through Mindfulness – AAFP video
50 Cognitive and Affective Biases in Medicine

“Attending” by Ronald Epstein, Mindfulness, & Prayer